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Kim Y, Kim JT, Yang SM, Kim WH, Han A, Ha J, Min S, Park SK. Anterior quadratus lumborum block for analgesia after living-donor renal transplantation: a double-blinded randomized controlled trial. Reg Anesth Pain Med 2024; 49:550-557. [PMID: 37704438 DOI: 10.1136/rapm-2023-104788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2023] [Accepted: 08/29/2023] [Indexed: 09/15/2023]
Abstract
INTRODUCTION Limited non-opioid analgesic options are available for managing postoperative pain after renal transplantation. We aimed to investigate whether the unilateral anterior quadratus lumborum (QL) block would reduce postoperative opioid consumption after living-donor renal transplantation in the context of multimodal analgesia. METHODS Eighty-eight adult patients undergoing living-donor renal transplantation were randomly allocated to receive the unilateral anterior QL block (30 mL of ropivacaine 0.375%) or sham block (normal saline) on the operated side before emergence from anesthesia. All patients received standard multimodal analgesia, including the scheduled administration of acetaminophen and fentanyl via intravenous patient-controlled analgesia. The primary outcome was the total opioid consumption during the first 24 hours after transplantation. The secondary outcomes included pain scores, time to first opioid administration, cutaneous distribution of sensory blockade, motor weakness, nausea/vomiting, quality of recovery scores, time to first ambulation, and length of hospital stay. RESULTS The total opioid consumption in the first 24 hours after transplantation did not differ significantly between the intervention and control groups (median (IQR), 160.5 (78-249.8) vs 187.5 (93-309) oral morphine milligram equivalent; median difference (95% CI), -27 (-78 to 24), p=0.29). No differences were observed in the secondary outcomes. CONCLUSIONS The anterior QL block did not reduce opioid consumption in patients receiving multimodal analgesia after living-donor renal transplantation. Our findings do not support the routine administration of the anterior QL block in this surgical population. TRIAL REGISTRATION NUMBER NCT04908761.
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Affiliation(s)
- Youngwon Kim
- Department of Anesthesiology and Pain Medicine and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
| | - Jin-Tae Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Seong-Mi Yang
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, Ulsan University College of Medicine, Seoul, Korea (the Republic of)
| | - Won Ho Kim
- Department of Anesthesiology and Pain Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Ahram Han
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Jongwon Ha
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Sangil Min
- Department of Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea (the Republic of)
| | - Sun-Kyung Park
- Department of Anesthesiology and Pain Medicine and Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea (the Republic of)
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Thakker PU, Temple DM, Minnick C, Ponzi D, Badlani G, Hemal A, Doares W, Webb C, McCracken E, Orlando G, Jay C, Farney A, Stratta RJ. Continuous flow local anesthetic wound infusion for post-operative analgesia following kidney transplantation. Clin Transplant 2024; 38:e15305. [PMID: 38567895 DOI: 10.1111/ctr.15305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/27/2024] [Accepted: 03/18/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Some patients with end stage renal disease are or will become narcotic-dependent. Chronic narcotic use is associated with increased graft loss and mortality following kidney transplantation. We aimed to compare the efficacy of continuous flow local anesthetic wound infusion pumps (CFLAP) with patient controlled analgesia pumps (PCA) in reducing inpatient narcotic consumption in patients undergoing kidney transplantation. MATERIALS AND METHODS In this single-center, retrospective analysis of patients undergoing kidney transplantation, we collected demographic and operative data, peri-operative outcomes, complications, and inpatient oral morphine milligram equivalent (OME) consumption. RESULTS Four hundred and ninety-eight patients underwent kidney transplantation from 2020 to 2022. 296 (59%) historical control patients received a PCA for postoperative pain control and the next 202 (41%) patients received a CFLAP. Median age [53.5 vs. 56.0 years, p = .08] and BMI [29.5 vs. 28.9 kg/m2, p = .17] were similar. Total OME requirement was lower in the CFLAP group [2.5 vs. 34 mg, p < .001]. Wound-related complications were higher in the CFLAP group [5.9% vs. 2.7%, p = .03]. Two (.9%) patients in the CFLAP group experienced cardiac arrhythmia due to local anesthetic toxicity and required lipid infusion. CONCLUSIONS Compared to PCA, CFLAP provided a 93% reduction in OME consumption with a small increase in the wound-related complication rate. The utility of local anesthetic pumps may also be applicable to patients undergoing any unilateral abdominal or pelvic incision.
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Affiliation(s)
- Parth U Thakker
- Department of Urology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Davis M Temple
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Caroline Minnick
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Dominick Ponzi
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | - Gopal Badlani
- Department of Urology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Ashok Hemal
- Department of Urology, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - William Doares
- Department of Pharmacy, Atrium Health Wake Forest Baptist, Winston-Salem, North Carolina, USA
| | - Christopher Webb
- Section of Transplantation, Department of Surgery, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Emily McCracken
- Section of Transplantation, Department of Surgery, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Giuseppe Orlando
- Section of Transplantation, Department of Surgery, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Colleen Jay
- Section of Transplantation, Department of Surgery, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Alan Farney
- Section of Transplantation, Department of Surgery, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Robert J Stratta
- Section of Transplantation, Department of Surgery, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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Sudin A, Chong C, Hassan R. Incidence and Factors Associated With Post-Sternotomy Pain Syndrome in the National Heart Institute, Malaysia. J Cardiothorac Vasc Anesth 2024; 38:466-474. [PMID: 38114372 DOI: 10.1053/j.jvca.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/09/2023] [Accepted: 11/03/2023] [Indexed: 12/21/2023]
Abstract
OBJECTIVE To determine the incidence of poststernotomy pain syndrome (PSPS) after open cardiac surgery in 2021. To determine characteristics and assess the severity of symptoms in patients diagnosed with PSPS. To identify factors that can be associated with patients who were positive for PSPS. DESIGN AND METHODOLOGY This study used a retrospective observational approach. Logistic regression analysis was employed to identify factors associated with the positive group. SETTING This study included all adult patients who underwent open cardiac surgery at the National Heart Institute, Malaysia, in 2021. PARTICIPANTS A total of 1,395 patients were enrolled. INTERVENTIONS The study involved conducting phone interviews to assess the presence of PSPS, followed by administering the Brief Pain Inventory questionnaire in the positive group to identify characteristics and severity of chronic pain. MEASUREMENTS AND MAIN RESULTS The incidence of PSPS after open cardiac surgery in 2021 was 20.35%. A total of 17.7% of patients reported that pain affected their daily activities, sleep, or emotions. Univariate analysis identified factors associated with PSPS, including age <60 years old, body mass index >30 kg/m2, history of previous percutaneous coronary intervention, ejection fraction <50%, the absence of chronic kidney disease (CKD), and internal mammary artery harvesting (p < 0.05). Multivariate analysis revealed that 4 independent factors were associated with PSPS: age <60 years old, history of previous percutaneous coronary intervention, ejection fraction <50%, and the absence of CKD (as compared with CKD) (p < 0.05). CONCLUSIONS Poststernotomy pain syndrome is a complex issue affected by various factors. Although the pain score may not be as severe as previously believed, it remains crucial to recognize PSPS because a significant proportion of patients are affected.
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Affiliation(s)
- Arif Sudin
- Anesthesia & Intensive Care department, National Heart Institute (IJN), Kuala Lumpur, Malaysia.
| | - Collins Chong
- Department of Anaesthesia & Intensive Care, Faculty of Medicine & Health Science, Universiti Putra Malaysia, Serdang, Selangor, Malaysia
| | - Rozaini Hassan
- Anesthesia & Intensive Care department, National Heart Institute (IJN), Kuala Lumpur, Malaysia
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Didik S, Golosova D, Xu B, Staruschenko A. Opioids and the Kidney: A Compendium. KIDNEY360 2023; 4:1816-1823. [PMID: 37927032 PMCID: PMC10758516 DOI: 10.34067/kid.0000000000000291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 10/19/2023] [Indexed: 11/07/2023]
Abstract
Opioids are a class of medications used in pain management. Unfortunately, long-term use, overprescription, and illicit opioid use have led to one of the greatest threats to mankind: the opioid crisis. Accompanying the classical analgesic properties of opioids, opioids produce a myriad of effects including euphoria, immunosuppression, respiratory depression, and organ damage. It is essential to ascertain the physiological role of the opioid/opioid receptor axis to gain an in-depth understanding of the effects of opioid use. This knowledge will aid in the development of novel therapeutic interventions to combat the increasing mortality rate because of opioid misuse. This review describes the current knowledge of opioids, including the opioid epidemic and opioid/opioid receptor physiology. Furthermore, this review intricately relates opioid use to kidney damage, navigates kidney structure and physiology, and proposes potential ways to prevent opioid-induced kidney damage.
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Affiliation(s)
- Steven Didik
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
- James A. Haley Veteran's Hospital, Tampa, Florida
| | - Daria Golosova
- Department of Physiology, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Biyang Xu
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
| | - Alexander Staruschenko
- Department of Molecular Pharmacology and Physiology, University of South Florida, Tampa, Florida
- James A. Haley Veteran's Hospital, Tampa, Florida
- Hypertension and Kidney Research Center, University of South Florida, Tampa, Florida
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Alomar D. Restorative Dental Treatment in a Patient with Mild–Moderate Chronic Kidney Disease (Stages 1–3). Dent Clin North Am 2023; 67:531-533. [DOI: 10.1016/j.cden.2023.02.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
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6
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Total Hip and Knee Arthroplasty in Solid Organ Transplant Patients: Perioperative Optimization and Outcomes. J Am Acad Orthop Surg 2022; 30:1157-1164. [PMID: 36476461 DOI: 10.5435/jaaos-d-22-00370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Accepted: 08/15/2022] [Indexed: 12/13/2022] Open
Abstract
The success of renal, liver, cardiac, pulmonary, and other solid organ transplantation (SOT) has resulted in increasing volume of transplant procedures and recipient survivorship. Subsequently, many SOT patients develop end-stage degenerative joint disease and are presenting for total hip or total knee arthroplasty more frequently. Surgeons must be aware of the medical complexities and prepare for the perioperative risks associated with these immunocompromised patients. Preoperative evaluation should be conducted in coordination with transplant specialists to ensure optimization, including appropriate surgical timing and advanced, organ-specific medical assessments. Although often unable to be modified, the transplant patient's antirejection medication regimens should be reviewed with understanding of inherent risks of poor wound healing or acute infection. Despite higher rates of complications, revision surgeries, and mortality compared with the general population, SOT recipients continue to demonstrate markedly improved pain relief, function, and quality of life. An ongoing multidisciplinary approach is required throughout the perioperative process and beyond to deliver successful outcomes after total joint arthroplasty in the SOT population.
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Dieterle M, Zurbriggen L, Mauermann E, Mercer-Chalmers-Bender K, Frei P, Ruppen W, Schneider T. Pain response to cannabidiol in opioid-induced hyperalgesia, acute nociceptive pain, and allodynia using a model mimicking acute pain in healthy adults in a randomized trial (CANAB II). Pain 2022; 163:1919-1928. [PMID: 35239547 PMCID: PMC9982727 DOI: 10.1097/j.pain.0000000000002591] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2021] [Revised: 11/25/2021] [Accepted: 12/21/2021] [Indexed: 10/19/2022]
Abstract
ABSTRACT Opioids in general and remifentanil in particular can induce hyperalgesia. Preclinical data suggest that cannabidiol might have the capacity to reduce opioid-induced hyperalgesia (OIH). Thus, we investigated the effect of oral cannabidiol on OIH in healthy volunteers using an established pain model. Twenty-four healthy participants were included in this randomized, double-blinded, crossover study and received either a 1600-mg single-dose oral cannabidiol or placebo. Hyperalgesia, allodynia, and pain were induced by intracutaneous electrical stimulation. To provoke OIH, participants recieved an infusion of 0.1 µg/kg/min remifentanil over a time frame of 30 minutes, starting 100 minutes after oral cannabidiol ingestion. The primary outcome was the area of hyperalgesia (in square centimetres) up to 60 minutes after remifentanil administration. The area of allodynia (in square centimetres) and pain (numeric rating scale) were also assessed.Cannabidiol had no significant effect on hyperalgesia, allodynia, or pain at any time point of measurement compared with placebo. The area of hyperalgesia after remifentanil administration significantly increased compared with baseline (17.0 cm 2 [8.1-28.7] vs 25.3 cm 2 [15.1-39.6]; P = 0.013). Mean cannabidiol blood levels were 4.1 ± 3.0 µg/L (mean ± SD) at 130 minutes after ingestion and were 8.2 μg/L ± 6.9 µg/L (mean ± SD) at 200 minutes. Cannabidiol was well tolerated. We conclude that a high single-oral dose of 1600-mg cannabidiol is not effective in reducing OIH. Before excluding an effect of cannabidiol on OIH, research should focus on drug formulations enabling higher cannabidiol concentrations.
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Affiliation(s)
- Markus Dieterle
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | - Laura Zurbriggen
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | - Eckhard Mauermann
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | | | - Priska Frei
- Institute of Forensic Medicine, Department of Biomedical Engineering, University of Basel, Basel, Switzerland
| | - Wilhelm Ruppen
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | - Tobias Schneider
- Clinic for Anaesthesia, Intermediate Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
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8
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Abdelrahman KAB, Abdelhakeem EE, Hussein Ali AR, Ismail EA. Transversus abdominis plane block versus paravertebral block for post-operative pain following open renal surgeries: A randomized clinical trial. EGYPTIAN JOURNAL OF ANAESTHESIA 2021. [DOI: 10.1080/11101849.2021.2000247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Affiliation(s)
- Khaled Abdel-Baky Abdelrahman
- Assistant Professor of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Assiut University, Assiut, Egypt
| | - Essam Ezzat Abdelhakeem
- Assistant Professor of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Eman Ahmed Ismail
- Assistant Professor of Anesthesia, Intensive Care and Pain Management, Faculty of Medicine, Assiut University, Assiut, Egypt
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9
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Ohnuma T, Horres CR, Raghunathan K, Bartz RR, Krishnamoorthy V, Brookhart MA, Kent ML. Trends in multimodal analgesics among end-stage renal disease patients undergoing lower extremity amputation in the US from 2009 to 2018. Br J Anaesth 2021; 128:e43-e45. [PMID: 34852927 DOI: 10.1016/j.bja.2021.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 10/13/2021] [Accepted: 10/19/2021] [Indexed: 11/20/2022] Open
Affiliation(s)
- Tetsu Ohnuma
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
| | - C Russell Horres
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | - Karthik Raghunathan
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA; Patient Safety Center of Inquiry, Durham VA Medical Center, Durham, NC, USA
| | - Raquel R Bartz
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
| | | | - M Alan Brookhart
- Department of Population Health Sciences, Duke University, Durham, NC, USA
| | - Michael L Kent
- Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA
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Narcotic Use for Acute Postoperative Pain Management in Mohs Micrographic Surgery Patients With End Stage Renal Disease: A Review of the Literature. Dermatol Surg 2021; 47:454-461. [PMID: 33625143 DOI: 10.1097/dss.0000000000002949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Uncontrolled acute postoperative pain presents a significant management challenge when opioids are used in patients with end-stage renal disease (ESRD). Currently, there is a lack of quality pharmacokinetic and pharmacodynamic data regarding opioid medication use in ESRD patients to optimize safe and effective management. OBJECTIVE To review the published literature on pharmacologic evidence for and against the use of opioid medications for acute postoperative pain following Mohs micrographic surgery in ESRD patients. METHODS A search of PubMed was conducted to identify articles on the pharmacokinetic and pharmacodynamic properties of opioid pain medications in ESRD patients through March 1, 2020. RESULTS Seventy-five articles were reviewed. Limited data exist on opioids safe for use in ESRD and are mostly confined to small case series. Studies suggest tramadol and hydromorphone could be considered when indicated. Methadone may be a safe option, but should be reserved for treatment coordinated by a trained pain subspecialist. CONCLUSION Randomized clinical trials are lacking. Studies that are available are not sufficient to perform a quantitative methodologic approach. Evidence supports the judicious use of postoperative opioid medications in ESRD patients at the lowest possible dose to achieve clinically meaningful improvement in pain and function.
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11
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Duan D, Yang L, Zhang M, Song X, Ren W. Depression and Associated Factors in Chinese Patients With Chronic Kidney Disease Without Dialysis: A Cross-Sectional Study. Front Public Health 2021; 9:605651. [PMID: 34123983 PMCID: PMC8192721 DOI: 10.3389/fpubh.2021.605651] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Accepted: 04/19/2021] [Indexed: 02/05/2023] Open
Abstract
Background: Chronic kidney disease (CKD) has been a globally public health problem over the past decades. The maintenance of physical and mental health is of importance for patients nowadays. Notably, depression is prevalent and associated with various adverse events in CKD patients without dialysis. Prior studies have reported that pain, negative illness perception, pain, and low self-esteem are potential risk factors of depression, while few studies have comprehensively investigated the mechanisms among these factors and depression among this population. Purpose: This study aims to investigate the prevalence of depression and further explore the factors associated with depression among CKD patients without dialysis in China. Design and Methods: We conducted a cross-sectional study in patients with diagnosed CKD to investigate the prevalence of depression was by the Beck Depression Inventory-II (BDI-II). The data on pain interference, illness perception, and self-esteem were also collected via self-administered questionnaires. A structural equation model (SEM) was used to examine the factors associated with depression. Main Findings: From June to October 2019, we successfully interviewed 334 CKD patients at the outpatient clinics. Their mean age was 45.6 years (ranging from 19 to 74 years), and 48.5% were male. Most respondents were at early CKD stages (77.5% stage 1–3) and the prevalence of depression was 22.2%. We found a moderate association between illness perception and depression, which was modified by self-esteem. Similar but weaker association was found between pain interference and depression. Conclusion and Recommendations: Negative illness perception, low self-esteem and severe pain interference were associated with depression among Chinese CKD patients without dialysis. Future studies are warranted to investigate the underlying mechanism and formulate the intervention strategies for this high-risk population.
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Affiliation(s)
- Difei Duan
- Department of Nephrology, West China Hospital, Sichuan University, Sichuan, China.,School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China.,West China School of Nursing, Sichuan University, Sichuan, China
| | - Lin Yang
- School of Nursing, The Hong Kong Polytechnic University, Hong Kong, China
| | - Min Zhang
- Department of Nephrology, West China Hospital, Sichuan University, Sichuan, China
| | - Xiaoli Song
- Department of Nephrology, West China Hospital, Sichuan University, Sichuan, China
| | - Wen Ren
- Department of Nephrology, West China Hospital, Sichuan University, Sichuan, China
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Dolati S, Tarighat F, Pashazadeh F, Shahsavarinia K, Gholipouri S, Soleimanpour H. The Role of Opioids in Pain Management in Elderly Patients with Chronic Kidney Disease: A Review Article. Anesth Pain Med 2020; 10:e105754. [PMID: 34150565 PMCID: PMC8207885 DOI: 10.5812/aapm.105754] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Revised: 07/19/2020] [Accepted: 08/20/2020] [Indexed: 12/13/2022] Open
Abstract
Chronic kidney disease (CKD) is a global public health problem. Pain is one of the most generally experienced symptoms by CKD patients. Pain management is a key clinical activity; nonetheless, insufficient pain management by health professionals keeps it up. Opioids as pain relievers are a class of naturally-derived and synthetic medications. They act through interactions with receptors in peripheral nerves. Numerous pharmacokinetic alterations happen with aging that influence drug disposition, metabolism, and quality of life. Acetaminophen alone, or combined with low-potency opioid dose is regarded as the safest pain-relieving choice for CKD. Morphine and codeine are probably eluded in renal impairment patients and used with excessive carefulness. Tramadol, oxycodone, and hydromorphone can be used by patient monitoring, while methadone, transdermal fentanyl, and buprenorphine seem to be safe to use in older non-dialysis patients with renal impairment. Consistent with the available literature, the main aim of this review was to explore the occurrence of chronic pain and its opioid treatment in CKD patients. According to this review, more and well-made randomized controlled trials are necessary to find appropriate opioid doses and explore the occurrence of side effects.
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Affiliation(s)
- Sanam Dolati
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
- Physical Medicine and Rehabilitation Research Center, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Faezeh Tarighat
- Student Research Committee, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Fariba Pashazadeh
- Research Center for Evidence-Based Medicine, Health Management and Safety Promotion Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Kavous Shahsavarinia
- Emergency Medicine Research Team, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Saina Gholipouri
- Department of Medical Sciences, University of Western Ontario, Ontario, Canada
| | - Hassan Soleimanpour
- Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran
- Corresponding Author: Aging Research Institute, Tabriz University of Medical Sciences, Tabriz, Iran. ,
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13
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Davani AB, Snyder SH, Oh ES, Mears SC, Crews DC, Wang NY, Sieber FE. Kidney Function Modifies the Effect of Intraoperative Opioid Dosage on Postoperative Delirium. J Am Geriatr Soc 2020; 69:191-196. [PMID: 33043446 DOI: 10.1111/jgs.16870] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2020] [Revised: 08/31/2020] [Accepted: 09/14/2020] [Indexed: 11/30/2022]
Abstract
BACKGROUND There are few studies demonstrating how kidney function affects the risk of developing delirium in older adult surgical patients administered opioids. This study determined whether baseline kidney function influences the relationship between morphine equivalent dose and the development of delirium on postoperative day (POD) 2 in patients with hip fracture. METHODS This retrospective study analyzed emergency department (ED) estimated glomerular filtration rate (eGFR), perioperative serum creatinine, intravenous morphine equivalents, and POD2 delirium assessment by the Confusion Assessment Method in 652 patients aged 65 years or older without preoperative delirium. ED eGFR was used to divide subjects into groups by presence or absence of chronic kidney disease (CKD), and associations of opioid dose with POD2 delirium were compared using multivariable logistic regression. RESULTS POD2 delirium incidence was 29.8% (N = 194). Intraoperative and postanesthesia care unit (PACU) morphine equivalent dosage as well as ED eGFR were similar comparing patients with and without POD2 delirium. Age, American Society of Anesthesiologists status, and dementia were associated with delirium on POD2. The odds of POD2 delirium increased significantly with increase of intraoperative opioid in patients with CKD (odds ratio = 1.6; 95% confidence interval = 1.2-2.2), but not in patients without CKD (P-interaction = .04). PACU or POD1 opioid doses were not associated with POD2 delirium after covariate adjustment. CONCLUSION This study suggests that incremental increases in intraoperative opioids combined with CKD increase odds of POD2 delirium after hip fracture repair, compared with patients without CKD.
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Affiliation(s)
- Arman B Davani
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Scott H Snyder
- Division of Geriatric and Palliative Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland, USA
| | - Esther S Oh
- Division of Geriatric Medicine and Gerontology, Psychiatry and Behavioral Sciences and Neuropathology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Simon C Mears
- Department of Orthopedics, University of Arkansas for Medical Sciences College of Medicine, Little Rock, Arkansas, USA
| | - Deidra C Crews
- Division of Nephrology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nae-Yuh Wang
- Department of Medicine, Johns Hopkins University School of Medicine; and Departments of Biostatistics and Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Frederick E Sieber
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
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Abstract
Pain is routinely reported in patients with chronic kidney disease. Pain is often multifaceted, making the treatment of this complex patient population even more challenging. Understanding pain types as well as treatment options for this patient population is an important skillset for the primary care provider.
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Abstract
The management of acute pain in older adults (age 65 or greater) requires special attention due to various physiologic, cognitive, functional, and social issues that may change with aging. Especially in the postoperative setting, there are significant complications that can occur if pain is not treated adequately for elderly patients. In this article, the authors describe these changes in detail and discuss how pain should be assessed appropriately in older patients. In addition, the authors detail the unique risks and benefits of several mainstream analgesic medications as well as interventional treatments for elderly patients. The authors' goal is to provide recommendations for health care providers on appropriately recognizing and treating pain in a safe, effective manner for aging patients.
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Affiliation(s)
- Jay Rajan
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Avenue, S-455, San Francisco, CA 94143, USA
| | - Matthias Behrends
- Department of Anesthesia and Perioperative Care, University of California, San Francisco, 513 Parnassus Avenue, S-455, San Francisco, CA 94143, USA.
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Soni S, Parmar K, Charan SM, Sethi S, Naik NB. Peritubal Infiltration of Fentanyl Compared to Dexmedetomidine with Ropivacaine in Percutaneous Nephrolithotomy: A Randomized Comparative Analysis. Anesth Essays Res 2019; 13:1-6. [PMID: 31031471 PMCID: PMC6444944 DOI: 10.4103/aer.aer_1_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Context: Dexmedetomidine has been found as an effective adjuvant in various nerve blocks. Despite several studies on dexmedetomidine with ropivacaine, there is no study on comparing with fentanyl in peritubal infiltration in percutaneous nephrolithotomy (PCNL). Aims: The aim of this study was to compare the effect of the addition of dexmedetomidine or fentanyl in peritubal local anesthetic infiltration on pain scores and analgesic consumption in patients who underwent PCNL. Settings and Design: This was a prospective, randomized, double-blind, tertiary care center-based study. Subjects and Methods: A total of 60 American Society of Anesthesiologists Class I, II, and III patients were selected and randomly divided into two groups: Group RF ropivacaine and fentanyl (n = 30) and Group RD ropivacaine and dexmedetomidine (n = 30). Balanced general anesthesia was given. After completion of the surgery, peritubal infiltration was given at 6 and 12 O’clock positions under fluoroscopic guidance. Postoperative pain was assessed using the visual analog scale and dynamic visual analog scale rating 0–10 for initial 48 h. Postoperative sedation was assessed using five-point sedation score. Time to first rescue analgesic, number of doses of tramadol, and total consumption of tramadol required in 48 h were noted. Statistical Analysis Used: Descriptive data were expressed in mean and standard deviation for between-group comparisons; the Chi-square and Fisher's exact tests were used for categorical variables, whereas t-test and Mann–Whitney U-test were used to compare continuous variables between two groups. Results: Duration of analgesia in group RD (12.87 ± 3.85) is more prolonged than group RF (8.13 ± 3.28) h. Total dose of rescue analgesia required in 48 h in group RF was higher as compared to group RD. Conclusions: Addition of dexmedetomidine to ropivacaine is more effective than fentanyl in terms of prolongation of analgesic efficacy of local anesthetic in peritubal block along with short-lived mild sedation.
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Affiliation(s)
- Sumit Soni
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | | | | | - Sameer Sethi
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Naveen B Naik
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
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Alizadeh R, Aghsaie Fard Z. Renal impairment and analgesia: From effectiveness to adverse effects. J Cell Physiol 2019; 234:17205-17211. [PMID: 30916404 DOI: 10.1002/jcp.28506] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2018] [Revised: 02/14/2019] [Accepted: 02/19/2019] [Indexed: 12/23/2022]
Abstract
Kidney pain is one of the clinically significant features of renal dysfunction. Mild to severe pain is seen in the lower back area. Painkillers are mostly recommended in these cases to relieve the symptom. Yet, several analgesics are associated with side effects that can worsen the state of the disease. This review is based on the studies conducted in these aspects analgesics used to treat kidney pain and their effectiveness, renal consequences of postoperative analgesia, and pharmacogenetics of these palliatives are briefly summarized in this paper.
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Affiliation(s)
- Reza Alizadeh
- Department of Anesthesiology and Intensive Care, AJA University of Medical Sciences, Tehran, Iran
| | - Ziba Aghsaie Fard
- Department of Internal Medicine, School of Medicine, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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Devoy B, Yaghmour KM, Chisari E, McDonnell SM, Khan W. Perioperative management of renal transplant patients undergoing total joint arthroplasty. J Perioper Pract 2019; 29:270-275. [PMID: 30888939 DOI: 10.1177/1750458919835435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The success of renal transplantation depends on lifelong immunosuppression. This can lead to a high incidence of avascular necrosis of major joints in the body for which arthroplasty is the treatment of choice. The risk of surgical complications is high in these patients, and there is no current set of cohesive perioperative management guidelines. In this review, we discuss the perioperative management of renal transplant patients undergoing elective total joint arthroplasty.
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Affiliation(s)
- Benjamin Devoy
- Division of Trauma & Orthopaedics Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Khaled M Yaghmour
- Division of Trauma & Orthopaedics Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Emanuele Chisari
- Division of Trauma & Orthopaedics Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Stephen M McDonnell
- Division of Trauma & Orthopaedics Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Wasim Khan
- Division of Trauma & Orthopaedics Surgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Houlind MB, Petersen KK, Palm H, Jørgensen LM, Aakjær M, Christrup LL, Petersen J, Andersen O, Treldal C. Creatinine-Based Renal Function Estimates and Dosage of Postoperative Pain Management for Elderly Acute Hip Fracture Patients. Pharmaceuticals (Basel) 2018; 11:E88. [PMID: 30231578 PMCID: PMC6160960 DOI: 10.3390/ph11030088] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 09/13/2018] [Accepted: 09/14/2018] [Indexed: 12/12/2022] Open
Abstract
Many analgesics and their metabolites are renally excreted. The widely used Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)-estimated glomerular filtration rate (eGFR) equations are not developed for use in the elderly, while the recent Berlin Initiative Study (BIS), Full Age Spectrum (FAS), and Lund-Malmö revised (LMR) equations are. This observational study investigated differences between creatinine-based eGFR equations and how the choice of equation influences dosage of analgesics in elderly (≥70 years) patients admitted with acute hip fracture. eGFR was calculated by the CKD-EPI, BIS, Cockcroft-Gault (CG), FAS, LMR, and Modification of Diet in Renal Disease (MDRD) equations. Standard daily dose for postoperative pain medications ibuprofen, morphine and gabapentin was simulated for each equation according to dosage recommendations in Renbase®. For 118 patients, mean eGFR from the CKD-EPI, BIS, CG, FAS, LMR, and MDRD equations was 67.3 mL/min/1.73 m², 59.1 mL/min/1.73 m², 56.9 mL/min/1.73 m², 60.3 mL/min/1.73 m², 58.9 mL/min/1.73 m², and 79.1 mL/min/1.73 m², respectively (p < 0.0001). Mean difference to CKD-EPI was -10.4 mL/min/1.73 m² to 11.8 mL/min/1.73 m². Choice of eGFR equation significantly influenced the recommended dose (p < 0.0001). Shifting to BIS, FAS, or LMR equations led to a lower recommended dose in 20% to 31% of patients. Choice of eGFR equation significantly influenced dosing of ibuprofen, morphine, and gabapentin.
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Affiliation(s)
- Morten Baltzer Houlind
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- The Capital Region Pharmacy, Marielundvej 25, 2730 Herlev, Denmark.
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
| | - Kristian Kjær Petersen
- Center for Sensory-Motor Interaction (SMI), Department of Health Science and Technology, Faculty of Medicine, Aalborg University, Fredrik Bajers Vej 7, building A2-206, 9220 Aalborg Ø, Denmark.
| | - Henrik Palm
- Orthopedic Department, Copenhagen University Hospital Bispebjerg, Bispebjerg Bakke 23, 2400 København, Denmark.
| | - Lillian Mørch Jørgensen
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
| | - Mia Aakjær
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- The Capital Region Pharmacy, Marielundvej 25, 2730 Herlev, Denmark.
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
| | - Lona Louring Christrup
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
| | - Janne Petersen
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- Section of Biostatistics, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Enterance B, 2nd floor, 1014 København, Denmark.
| | - Ove Andersen
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- Emergency Department, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 436, 2650 Hvidovre, Denmark.
| | - Charlotte Treldal
- Optimed, Clinical Research Centre, Copenhagen University Hospital Hvidovre, Kettegård Alle 30, Department 056, 2650 Hvidovre, Denmark.
- The Capital Region Pharmacy, Marielundvej 25, 2730 Herlev, Denmark.
- Section of Pharmacotherapy, Department of Drug Design and Pharmacology, University of Copenhagen, Universitetsparken 2, 2100 København Ø, Denmark.
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20
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O'Brien T, Christrup LL, Drewes AM, Fallon MT, Kress HG, McQuay HJ, Mikus G, Morlion BJ, Perez-Cajaraville J, Pogatzki-Zahn E, Varrassi G, Wells JCD. European Pain Federation position paper on appropriate opioid use in chronic pain management. Eur J Pain 2018; 21:3-19. [PMID: 27991730 PMCID: PMC6680203 DOI: 10.1002/ejp.970] [Citation(s) in RCA: 135] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2016] [Indexed: 02/06/2023]
Abstract
Poorly controlled pain is a global public health issue. The personal, familial and societal costs are immeasurable. Only a minority of European patients have access to a comprehensive specialist pain clinic. More commonly the responsibility for chronic pain management and initiating opioid therapy rests with the primary care physician and other non‐specialist opioid prescribers. There is much confusing and conflicting information available to non‐specialist prescribers regarding opioid therapy and a great deal of unjustified fear is generated. Opioid therapy should only be initiated by competent clinicians as part of a multi‐faceted treatment programme in circumstances where more simple measures have failed. Throughout, all patients must be kept under close clinical surveillance. As with any other medical therapy, if the treatment fails to yield the desired results and/or the patient is additionally burdened by an unacceptable level of adverse effects, the overall management strategy must be reviewed and revised. No responsible clinician will wish to pursue a failed treatment strategy or persist with an ineffective and burdensome treatment. In a considered attempt to empower and inform non‐specialist opioid prescribers, EFIC convened a European group of experts, drawn from a diverse range of basic science and relevant clinical disciplines, to prepare a position paper on appropriate opioid use in chronic pain. The expert panel reviewed the available literature and harnessed the experience of many years of clinical practice to produce these series of recommendations. Its success will be judged on the extent to which it contributes to an improved pain management experience for chronic pain patients across Europe. Significance This position paper provides expert recommendations for primary care physicians and other non‐ specialist healthcare professionals in Europe, particularly those who do not have ready access to specialists in pain medicine, on the safe and appropriate use of opioid medications as part of a multi‐faceted approach to pain management, in properly selected and supervised patients.
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Affiliation(s)
- T O'Brien
- Marymount University Hospital & Hospice, Curraheen, Cork, Ireland.,Cork University Hospital, Wilton, Cork and College of Medicine and Health, University College, Cork, Ireland
| | - L L Christrup
- Department of Drug Design and Pharmacology, University of Copenhagen, Denmark
| | - A M Drewes
- Mech-Sense, Department of Gastroenterology & Hepatology, Aalborg University Hospital, Denmark
| | - M T Fallon
- Edinburgh Cancer Research Centre, University of Edinburgh, UK
| | - H G Kress
- Department of Special Anaesthesia and Pain Therapy, Medical University of Vienna/AKH, Austria
| | | | - G Mikus
- Department of Clinical Pharmacology and Pharmacoepidemiology, University Hospital, Heidelberg, Germany
| | - B J Morlion
- Leuven Centre for Algology & Pain Management, University Hospital Leuven, Belgium
| | | | - E Pogatzki-Zahn
- Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Müenster, Germany
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Singh PM, Borle A, Makkar JK, Trisha A, Sinha A. Evaluation of transversus abdominis plane block for renal transplant recipients - A meta-analysis and trial sequential analysis of published studies. Saudi J Anaesth 2018; 12:261-271. [PMID: 29628838 PMCID: PMC5875216 DOI: 10.4103/sja.sja_598_17] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Background Patients undergoing renal transplant (RT) have altered drug/opioid pharmacokinetics. Transversus abdominis plane (TAP) block in renal transplant recipients has been recently evaluated for analgesic and opioid-sparing potential by many trials. Methodology The studies comparing TAP-block to conventional analgesic regimens for RT were searched. Comparisons were made for total opioids consumed (as morphine-equivalents) during the first postoperative 24-h (primary objective), intraoperative, and immediate-postoperative period. Pain scores and postoperative nausea-vomiting (PONV) were also evaluated. Trial sequential analysis (TSA) was used to quantify the strength of analysis. Results Ten-trials with 258 and 237 patients in control and TAP-block group, respectively, were included. TAP-block decreased the 24-h (reported in 9-trials) opioid consumption by 14.61 ± 4.34 mg (reduction by 42.7%, random-effects, P < 0.001, I2 = 97.82%). Sample size of the present analysis (472) was well past the required "information-size" variable (396) as per the TSA for a power of 85%. Intraoperative opioid consumption also decreased by 2.06 ± 0.63 mg (reduction of 27.8%) (random effects, P < 0.001, I2 = 98.84%). Pain scores with TAP-block were significantly lower in both early and delayed postoperative phase. Odds ratio for PONV without TAP block was 1.99 ± 1.05 (Fixed-effects, P = 0.04, I2 = 0%). Publication bias was likely (Egger's test, X-intercept=7.89, P < 0.05). Conclusions TAP-block significantly lowers the intraoperative and cumulative postoperative 24-h opioid consumption in RT recipients. Persistent and better pain control is achieved when TAP-Block is used. Benefits of TAP block extend beyond the analgesic actions alone as it also decreases the 24-h incidence of postoperative nausea vomiting as well. The technique of the block needs standardization for RT recipients.
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Affiliation(s)
- Preet Mohinder Singh
- Department of Anesthesia, Pain Medicine & Intensive Care, All India Institute of Medical Sciences, New Delhi, India
| | - Anuradha Borle
- Department of Anesthesia, Pain Medicine & Intensive Care, All India Institute of Medical Sciences, New Delhi, India
| | - Jeetinder Kaur Makkar
- Department of Anesthesia, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aanjan Trisha
- Department of Anesthesia, Pain Medicine & Intensive Care, All India Institute of Medical Sciences, New Delhi, India
| | - Aashish Sinha
- Department of Anesthesia, Temple School of Medicine, Philadelphia, PA, USA
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Hydromorphone Hydrochloride Use During Various Interventional Radiology Procedures-Pain Control and Adverse Events: A Case Series Audit Analysis. Pain Ther 2017; 6:217-225. [PMID: 29080097 PMCID: PMC5693814 DOI: 10.1007/s40122-017-0083-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2017] [Indexed: 02/08/2023] Open
Abstract
Introduction This project studied pain control and the development of adverse events before, during, and after the administration of hydromorphone hydrochloride for various interventional radiology (IR) procedures. Methods We performed a retrospective analysis of 100 patients (men = 58; women = 42) sedated with peri-procedural intravenous (IV) hydromorphone in association with various IR procedures. We stratified the procedures as follows: abscess drainages (M = 8; F = 8), arteriograms (M = 1; F = 0), biliary interventions (M = 3; F = 2), bone biopsies (M = 2; F = 2), non-bone biopsies (M = 26; F = 19), non-tunneled venous catheters (M = 1; F = 1), tunneled venous catheters (M = 7; F = 5), embolization (M = 4; F = 0), IVC filter placement (M = 1; F = 1), nephrostomy tube placement (M = 1; F = 4), and percutaneous nephrolithotomy tube placements (M = 4; F = 0). We recorded the pre-, intra-, and post-procedure pain scores [numeric rating scale (NRS) with 0 = no pain to 10 = most pain] for each of the stratifications. We also recorded the total dose of hydromorphone and midazolam hydrochloride received by each gender, as well as whether any men or women received either naloxone hydrochloride or any antiemetic. Lastly, the investigators recorded the development of hypotension following hydromorphone administration and/or hypoxia as well as the need for opioid-induced intensive care unit (ICU) admission. The investigators used unpaired, two-tailed t tests, and either Yates-corrected Chi-squares or two-tailed Fisher’s exact tests for continuous and categorical variables, respectively. The difference was statistically significant if p < 0.05. Results There was no significant difference between men and women for either mean age (M = 50 years; F = 53.4 years) or mean pre-procedural pain scores (M = 1.31; F = 0.55). There was no statistically significant difference in numbers of men or women for each procedure stratification. The highest mean pre-procedure pain score was in men undergoing percutaneous nephrostomy tube placement (mean 5, SD 0). The highest mean intra-procedure pain score was in men undergoing abscess drainages (mean 2, SD 2.3). The highest mean post-procedure pain score was in men undergoing abscess drainages (mean 1.5, SD 3.5). The only mean scores that were significantly different between men and women were in pre- (M = 2.5; F = 0.6; p = 0.006) and intra-procedural (M = 2; F = 0.5; p = 0.0001) pain scores for abscess drainages. There was no statistically significant difference in the dose of either hydromorphone (M = 1.3; F = 1.3) or midazolam (M = 1.3; F = 1.3) administered. There was no statistically significant difference in opioid-induced nausea (M = 1; F = 3). One female experienced hypotension and one male experienced hypoxia within 6 h of hydromorphone administration. There were neither opioid-related ICU admissions nor naloxone administrations. Conclusions This preliminary study indicates that IV hydromorphone ± midazolam may be a safe and effective analgesic and sedative combination for adult patients undergoing IR procedures. Electronic supplementary material The online version of this article (doi:10.1007/s40122-017-0083-4) contains supplementary material, which is available to authorized users.
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Kent ML, Hsia HLJ, Van de Ven TJ, Buchheit TE. Perioperative Pain Management Strategies for Amputation: A Topical Review. PAIN MEDICINE 2017; 18:504-519. [PMID: 27402960 DOI: 10.1093/pm/pnw110] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Objective To review acute pain management strategies in patients undergoing amputation with consideration of preoperative patient factors, pharmacologic/interventional modalities, and multidisciplinary care models to alleviate suffering in the immediate post-amputation setting. Background Regardless of surgical indication, patients undergoing amputation suffer from significant residual limb pain and phantom limb pain in the acute postoperative phase. Most studies have primarily focused on strategies to prevent persistent pain with inclusion of immediate postoperative outcomes as secondary measures. Pharmacologic agents, including gabapentin, ketamine, and calcitonin, and interventional modalities such as neuraxial and perineural catheters, have been examined in the perioperative period. Design Focused Literature Review. Results Pharmacologic agents (gabapentin, ketamine, calcitonin) have not shown consistent efficacy. Neuraxial analgesia has demonstrated both an opioid sparing and analgesic benefit while results have been mixed regarding perineural catheters in the immediate post-amputation setting. However, several early studies of perineural catheters employed sub-optimal techniques (distal surgical placement), and prolonged use of perineural catheters may provide a sustained benefit. Regardless of analgesic technique, a multidisciplinary approach is necessary for optimal care. Conclusion Patient-tailored analgesic regimens utilizing catheter-based techniques are essential in the acute post-amputation phase and should be implemented in all patients undergoing amputation. Future research should focus on improved measurement of acute pain and comparisons of effective analgesic regimens instead of single techniques.
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Affiliation(s)
- Michael L Kent
- Department of Anesthesiology, Walter Reed National Military Medical Center, Uniformed Services University of the Health Sciences, Bethesda, Maryland, USA
| | - Hung-Lun John Hsia
- Department of Anesthesiology, Duke University Medical Center, Durham VA Medical Center, Durham, North Carolina, USA
| | - Thomas J Van de Ven
- Department of Anesthesiology, Duke University Medical Center, Durham VA Medical Center, Durham, North Carolina, USA
| | - Thomas E Buchheit
- Department of Anesthesiology, Duke University Medical Center, Durham VA Medical Center, Durham, North Carolina, USA
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